Provider Demographics
NPI:1023447356
Name:KELLOUGH, THOMAS (COTA)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:KELLOUGH
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:835 MADISON AVE N
Mailing Address - Street 2:
Mailing Address - City:BAINBRIDGE ISLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98110-1700
Mailing Address - Country:US
Mailing Address - Phone:206-842-4765
Mailing Address - Fax:
Practice Address - Street 1:835 MADISON AVE N
Practice Address - Street 2:
Practice Address - City:BAINBRIDGE ISLAND
Practice Address - State:WA
Practice Address - Zip Code:98110-1700
Practice Address - Country:US
Practice Address - Phone:206-842-4765
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-07
Last Update Date:2013-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA0C00000849224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant